Newspaper/Magazine Article

The concept of proactively responding to medical mistakes through disclosure and compensation has gained acceptance in recent years. This news article reports on federal and local efforts to transparently manage the consequences of adverse events.

Journal Article > Commentary

Biased physician recommendations can undermine safe, patient-centered care. This commentary and related perspective illustrate how unneeded treatment for breast cancer represents the problem of overdiagnosis and describe the subsequent harm to patients. The author suggests that physicians should provide patients with a range of treatment options along with their associated risks and benefits, consider patients' preferences, and encourage shared decision-making.

Telemedicine is being more widely used in order to increase access to care. A relatively new aspect of telemedicine is direct-to-consumer telemedicine, including teledermatology. Using secret shoppers who submitted photographs and clinical information to teledermatology sites, this study found poor diagnostic accuracy and failure to elicit important information. Other studies have also raised concerns about the diagnostic accuracy of virtual clinical visits.

This study reports on the development of a checklist to prevent errors in vaccine dosing, timing, and administration in primary care. The checklist was based on review of adverse event data and focus groups with clinicians and caregivers.

Journal Article > Commentary

Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient mortality increases during the July transition—truly exists. This commentary describes how leadership, supervision, mentor–learner pairings, and communication enhancement can help to reduce risks in this period. The authors suggest that applying strategies from aviation to augment teamwork between interns and residents could be an effective improvement strategy.

Journal Article > Study

Multiple studies have documented that patients with various conditions admitted over the weekend have worse outcomes than those admitted on a weekday. This large retrospective study did not find any difference in inpatient mortality for patients admitted to a psychiatric ward on the weekend. However, these patients had shorter admissions and were more likely to be readmitted, and the authors felt that these findings were most likely attributable to inherent differences in the types of psychiatric patients admitted on weekends.

The I-PASS standardized handoff protocol is considered the gold standard for inpatient handoffs, having been shown to reduce adverse events among hospitalized patients. In this study, implementation of I-PASS within an electronic medical record resulted in an improvement in handoff quality among pediatric residents. A recent PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.

Standardized handoff protocols have been shown to reduce adverse events among hospitalized patients. This study reports on the development and validation of a tool for assessing the quality of verbal handoffs between pediatric residents. The tool demonstrated excellent potential for evaluating resident handoff skills, but the authors note that observation of more than 20 handoffs per resident would be required to determine competency.

Journal Article > Study

This analysis of incident reports found that problems with handling patient clinical information were a common source of preventable adverse events. These incidents were often due to workarounds, such as recording patient information on paper instead of within the electronic medical record.

Journal Article > Commentary

In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.

Journal Article > Study

Centers for Medicare and Medicaid Services star ratings are based on patient experience surveys, and the relationship between such ratings and patient outcomes has not been well-established. This secondary data analysis found that hospitals with higher star ratings had lower 30-day mortality and readmission rates. The authors suggest that these ratings may lead patients to higher-performing hospitals.

Journal Article > Study

Early intervention for sepsis can improve patient outcomes, and in turn prompt diagnosis is critical. Using case vignettes, this survey of intensivists found substantial variation in accurately diagnosing sepsis. This work has significant implications for initiatives aimed at improving the timely recognition of this condition.

Interhospital transfers have similar risks as other care transitions, but less is known about them. This descriptive study found variation in the training and experience of transfer care coordinators and communication practices in handoffs. Standardization in these practices should enhance patient safety.

Journal Article > Review

Patient participation is considered a key component of patient safety initiatives. This review examined patient engagement programs and policies and determined that the current methods do not result in true public involvement in safety improvement. The authors suggest broader strategies are needed to engage the public in co-designing a safer health care system.

Journal Article > Study

In this study performed in a community behavioral health center, medication reviews by pharmacists helped improve appropriate monitoring of patients prescribed high-risk psychotropic medications. A WebM&M commentary describes a case of a potentially harmful medication error in an outpatient psychiatry clinic.

Journal Article > Study

According to this qualitative study at a single academic institution, staff surgeons and intensivists frequently exclude resident physicians from patient care conversations. Reasons included lack of trust, need for timely communication, and a perception that residents cannot adequately contribute to decision making. This finding has important implications for the integration of communication training during medical education.

Journal Article > Study

This retrospective cohort study showed no improvement in 30-day pediatric perioperative complication rates following the mandated implementation of the surgical safety checklist in Ontario. These findings are similar to a prior study that included mostly adult surgeries.

Journal Article > Study

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.